Letter to the Editor

DEAR EDITOR

RE: RARE CASE OF TRICHOBEZOAR

Trichotillomania, which is currently classified as an impulse control disorder, has a prevalence of 0.6%–1.6% (1). However, there is an increased incidence of obsessive-compulsive disorder (OCD) in patients with trichotillomania and phenomenologically these two conditions are similar, suggesting that trichotillomania can be thought of as an OCD spectrum disorder (2). Literature review shows dozens of case reports, which demonstrate the various forms of presentations. Although usual presentation is hair pulling from the scalp, there are other targets for pulling, i.e. eyebrows, eyelashes, armpits, legs, and pubic area. Furthermore 30% of those who suffer from trichotillomania engage in trichophagia, and only 1% go on to develop trichobezoar. Trichobezoar was first described by Baudomant in 1779 (3). It is a recognized cause of chronic abdominal pain, usually requiring surgical removal (4), which undiagnosed may lead to serious complications such as in gastric ulcers bleeding and perforation, intussusception, and small bowel obstruction (5). In adults the reported mortality rates are as high as 30% (6).

CASE REPORT

M. is a 14 year old, grade 9 student, who lives with his father since parental divorce when he was 2 months old. Mike was brought to the ER with severe abdominal pain. Two days later he underwent laparotomy when large mass of hair filling stomach and proximal duodenum was removed. In addition, an anterior perforated gastric ulcer and a number of other gastric ulcers, were found.

A child psychiatric consult was requested and the history revealed no past psychiatric problems. M. had always denied hair pulling or swallowing and was surprised at the discovery of hair in his stomach. He could not recall ever having pulled or swallowed his hair. The history revealed that about one and half year ago M. had a number of stressors: the death of his beloved grandmother, a new school and a fractured leg. During this time he started to develop bald patches, which were then diagnosed by a dermatologist as a traumatic alopecia. He adamantly denied hair pulling and his father never observed him doing so either. His hair eventually grew back.

Developmental history showed milestones on time and a healthy boy. His mother left the family when M. was 2 months old and he was raised by his father. He never had any behavioral problems and has always been a shy and timid child. His father’s only concern was around his school attendance and poor academic performance. He does not find classes interesting and stated that he prefers to play computer games and hang out with his friends.

On further examination, M. was told that charges of truancy will be brought against him if he does not return to school. Although M. returned to school he developed severe anxiety, depressed mood, and poor sleep for a few day. Shortly after, father, again, notice alopecia but M. continued to deny hair pulling.

M. had an academic assessment done through school, which revealed an average Intelligence and no learning disorders. On mental status exam M. appeared his stated age, he was cooperative and made good eye contact. He had thin long hair and no bald patches were visibly obvious. He was puzzled and surprised that a hairball was found in his stomach. His mood was normal, and affect was appropriate. There was no indication of the presence of psychotic symptoms. He denied any symptoms of anxiety, phobia, or panic attacks, or sleep disturbance, even though that there was a clear history of school refusal and anxious personality traits. He did not endorse any suicidal/ homicidal ideation. Cognitively he appeared to have an average intelligence and was oriented to place, time, and person. He did not have any insight into his illness, as he hadn’t been aware of his hair pulling. At the time of this writing M. has been on the surgical ward for 4 days. There were no post-op complications.

As evident from this case report, patients are not always aware that they are pulling their hair. Clinical studies show there are two types of this disorder: “focused” type, when time and attention are set aside specifically for the purpose of hair pulling, and “automatic” or “sedentary” type, in which subjects pull their hair while engaged in other activities, such as lying in bed, driving, or watching television. Some patients with trichotillomania have other associated oral behavior, such as running the hair across their lips, biting the root, or eating the hair (7). Due to significant psychiatric comorbidity, such as depression, anxiety, OCD, body dysmorphic disorder, eating disorder, alcohol and substance abuse (8, 9, 10) and physical complications of trichotillomania and trichophagia, such as infection of the scalp, repetitive stress injury, carpal tunnel syndrome, gastrointestinal blockage and perforation (4, 11), as well as trichobezoars formation, it is extremely important to diagnose and treat this disorder as early as possible.

M.’s case highlights the importance of considering tricholtillomania in the differential diagnosis for alopecia. Early diagnosis and treatment of underlying psychopathology, which in this case, may well include an attachment disorder and, certainly, an anxiety disorder, may have led him to the progression of his trichotillomania and to the formation of a trichobezoar with consequent gastric ulcer perforation.